Creative Worship Registration
Saturdays beginning March 9 (Performance May 5)
Bethel Friends Church 2771 Spitler Road Poland, OH 44514
Contact us at (330) 757-1555 or bethel2771@gmail.com
Child's First Name *
Your answer
Child's Last Name *
Your answer
Gender *
Street Address *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Phone Number *
Your answer
Birthdate *
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Age *
Your answer
Guardian *
Your answer
Relationship to Student *
Your answer
E-mail
Your answer
Mark the appropriate class *
Required
I understand that payment is due on or before Saturday, March 9 (payment is accepted via cash or check) *
Required
WAIVER AND INFORMED CONSENT STATEMENT (electronic signature required): I hereby give consent for my child to participate in Bethel Friends Church dance classes. I declare myself or him/her medically able to participate in activities through Bethel Friends Church. I understand that there may be risks which may include disabling injury and/or death involved in all physical activities and I agree to hold free from any liability the Bethel Friends Church and its respective officers, employees, members, volunteers, and sponsors and do hereby for myself, my heirs, executors, and administrators waive, and release and forever discharge any and all rights and claims for damages which myself or my child may have or which may accrue to myself or him/her arising out of or connected with my or his/her participation in any of the activities of the Bethel Friends Church. I have been appraised of and acknowledge the particular hazard and potential danger involved in my or my child's participation in the 2019 dance year. I hereby authorize Bethel Friends Church (as well as license others) to use, reproduce, distribute, and display my child's image, and photograph, as well as any video, digital, or audio recording or communications of Bethel Friends Church for the sole purpose of advancing activities within Bethel Friends Church. Signature of Parent of Guardian (by typing your name below, it acts as your signature)
Your answer
Date of Signature *
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Emergency Contact *
Your answer
Phone Number *
Your answer
Second Contact *
Your answer
Phone Number *
Your answer
Hospital Preferred *
Your answer
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